Denied pump--numbers are TOO GOOD? ARE YOU KIDDING ME?

I have been denied my pump coverage and Dexcom CGM every time I have tried to get a new one. I am a Type 1 Diabetic for over 20 years. Definitely appeal the decision. I think they automatically well unless maybe if someone is pregnant. The first time I appealed an insulin pump denial I sent a letter along with it to my insurance stating that having an insulin pump and Dexcom is a lot less money than one trip to the emergency room. Lol. They approved after that. But definitely a doctor sending that it is necessary with help too.

I was so resistant to a pump due to fear of overdose and dka, but in retrospect I should have started it much sooner. My doc wanted me to at that time.

For me it was a big learning curve( filling the cartridge/tubing with insulin etc. dealing with the alarms were the worst part and fear of making an insulin error) and it was stressful- I remember asking for advice here about the tubing and all and getting some ridiculous replies telling me I shouldn’t use a pump .
The first day it almost gave me a feeling of what I used to be like because I remember I had a very smooth transition to the fast acting as basal and I felt a sense of calm. That didn’t last though and my bg went a bit more crazy from my team reducing all insulin too much. I think everything that can go wrong did in the first two weeks or so which just about made me say forget it but I knew it had to better than mdi for me and I refused to give up.

In fact though, you can make much worse errors with injections mixing up your basal and fasting acting and things like that. The pump calculates everything for you so as long as you’re careul typing in what you want you should be ok. You set your maximum bolus so you won’t be able to dose more than that without giving a second ok for that. In fact I don’t think I can do more than mine- I have to do a double bolus if I want to which I’ve only done maybe 2-3x. Mine is 5 units because I’m so insulin sensitive now. I remember taking 7 units for a meal when I was released from the icu and ending up at 250 bg at home. Now that dose would be an overdose for me.

I remember my trainer telling me, she was type 1 also since she was a child and this was her second pump, that “they” pwithoutd will never understand how we feel and all the fear we go through, and she much preferred the pump. I found things in the manual, which was part of my training reading that she wasn’t aware of, lol. she said I needed to have more confidence in my ability etc. My bg was totally crazy during that period on mdi, I remember it jumping about 100 points while we sat there during one session and she was helping me figure out what was going on- she thought I had skipped my basal maybe but it wasn’t that- there was no real explanation which is not uncommon for me.

I also didn’t want devices attached to me etc. and I’m very pain sensitive. It does give me much better ability to manage things so I tolerate the bad parts. There is NOTHING like knowing you can shut off your insulin to help treat lows, just that fact alone makes me feel much safer. My cde mentioned there is a new pump, I’ve forgotten which one, coming out soon, which will decrease your basal rate when your bg drops, not a total suspension like some do, so as your bg rises you will still have basal insulin.

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here in spain, your experience is par for the course. im in good control and unless my a1c is over 8 for a year, i will not be granted a pump or cgm. even if it were, there would probably be no money for it. i could also get one and actually considered doing a bit of an overdose of insulin at a friends house and having her call and ambulance 3 times-the whole hyp unaware thing. seriously.
i would also get more strips if i werent well controlled.
it does seem like being punished for being in control. ridiculous. im sorry youre not able to get the new technology either. i would love the option, too.
good luck withthe appeal. i think you should do it. the worse thing they can say is “no”, and theyve already said it.

I really do want to appeal, but will it even be worth it without the support of my Endo? All of this just has me so down! This whole time I’ve been trying to be so meticulous with my care while in my head thinking this is what they want! They want to see how good I can manage this! Then boom, nope! Numbers are too good! After being denied I got into some bad habits for a few days, and I kind of just had the mindset of, “What’s the point???” My numbers ran quite a bit higher for those few days. I snapped out of it though. I know I can’t just take a break from diabetes, but it’s hard not to knowing that my numbers need to be higher before they will approve me. Right now I am looking into switching to a new provider. We will see I guess.

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If you aren’t happy with your endo, maybe consider getting a second opinion.

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Good control / good numbers was also the reason I was denied a pump. My doctor was told that UHC would only approve a pump for me if my numbers were over 500 “frequently” or if my HbA1c was over 9.5. The fact that I was having regular (daily) hypoglycemia episodes did not impress them – in fact, they said they’d approve a CGM for the hypos, then promptly denied that, as well, a week later!

This tendency for insurers to find any excuse to maximize short-term profitability by minimizing care – even though the long-term consequences could be significantly more expensive care (hopefully paid for by another insurer?) is a big problem with the healthcare system in the US. Cost-wise, this is a recipe for long-term disaster – and the health consequences for many may be devastating!

Saw a paper this week that scares me, as it seems to potentially grant a “license” for insurers to further deny people with Type 2 the option of intensive insulin therapy: Intensive treatment of glucose levels can lead to serious complications -- ScienceDaily. It’s one thing if this study is used by individual patients’ doctors to make treatment decisions, but I have no doubt that insurers will jump in and start directing patient care, using this study as evidence!

That study is very worrying, as you say. What I don’t get is that it seems entirely possible that the people who are well-controlled and taking more medicine (including insulin) are well-controlled precisely because of that medicine. Taking it away therefore seems like an idiotic solution.

This is ultimately the evil root of why health care in the United States is continuing to approach the vortex surrounding the drain!

Did you get this resolved? If not, I may have some insight for you. I have BCBS as well and was initially denied, but after I appealed, it was approved. It was a long process, but definitely worth it.

I work at a hospital, and we have a self funded plan. BCBS just serves as the “claims administrator”, so it was actually my employer that denied the claim. I do have an appointment with a new provider in July and I plan on speaking with her about appealing, so I’m not giving up hope yet! Glad to hear it worked out for you!!

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I was recently diagnosed like you and will be asking some questions tomorrow. Keep us updated. I’m sure mine will be denied. I think my a1c will hopefully be down a lot.

Change your endo!!!

Scanning through this, the reply that referenced the peptide test which gives evidence that you’re a T1 is the only thing you should consider going forward.

I also noticed the several comments regarding Medicare not covering a CGM. Of all the many things that I find wrong with Medicare, this may be the only thing with which I agree. Medicare’s position is that the CGM is a redundant test expense. It is. If you follow the CGM instructions and manually test every time you get an alarm or warning, you probably will be testing four to eight times a day. Guess what? If you test that frequently without being told to do so by the CGM, you find you stay in much tighter control with very infrequent concerns. You do, however, have to get your doctor to convince Medicare why you need to exceed their normal three tests per day coverage.

All this said, I can’t imagine controlling my blood glucose that last ten years without a pump!

@jtenneson

I also hope you come back and let us know if everything has worked out in your favor.

Hi, I’ve used insulin pumps since 1990. Two years ago I moved to Brazil and, of course, the pump that I use (Animas) is not sold down here, so I can’t get supplies. So I started 2 years ago trying to get another pump, from Medtronic, which IS sold here. The system here is very strange. You don’t go through an insurance company. You have to sue the government to get a pump. So, first you have to file for one with a prescription from your doctor, then you have to get a letter of rejection, which is automatic, then you have to get a lawyer and sue the government. The whole process takes about 2 years. And just 2 weeks ago I got word from the lawyer that my pump has been approved. (More on that in a minute.) To your point, in the process I was told that I needed to turn in “bad” numbers in order to get my pump approved. Now, I have been fairly controlled for YEARS!! So, imagine my dilema when told that my numbers have to be “bad”. Well, fortunately (or actually, unfortunately) I have gotten to a place where I don’t feel my lows and have been having a lot of hypoglycemia episodes. This has affected everything and I have swung back and forth a LOT! Even though my BGs have been high, I’ve also had so many lows that at one point my A1C was 4.0!!! Ridiculous and dangerous, of course. (I haven’t been able to afford the Dexcom supplies that go with my Animas Vibe pump.) Anyway, back to my story, finally the judge’s decision was to approve my pump. The kicker is that now I’m not even assured of getting the Medtronic pump with the sensor (in the States it’s their 530G pump with CGM, in Brazil it’s called a VEO) because the “doctors” who evaluated my case concluem that both the Medtronic pump and the Roche pump (Accucheck) are comparable and will serve my needs equally. This is hogwash, of course, because there is no sensor with the Roche pump. And, what determines which pump I will get is the lowest bid put forth by the two companies!! So, the good news is that I’m at least getting a pump and don’t have to go back to taking 4 shots a day, which I did from 1980 to 1990. But now, when I can’t feel my lows, I may not have a shot at a CGM unless I go back to the States!! I have dual citizenship and my husband is American. We came to Brazil after retirement to live. Up to now, we’ve been loving it. But other health issues have crept up, in addition to this pump situation, so I’m not sure how long living down here is going to last. I have to say that I’m healthier down here than I have ever been–all the fresh fruit and vegetables and slower pace of life, etc. But in spite of free public health care, life has been hard. Will let you know how the pump thing turns out. After the mandate (decision) is passed along to the court officials, the state has 15 days to provide me my pump (or they face steep fines), so we’re talking a max of a month from now when I will supposedly have my new pump. But this is Brazil, after all, not everything pans out as it should.

Glad to hear Medicare does cover a pump as I may have to try for that when I return to the States (see my reply to jtenneson on getting a pump in Brazil.)

Wow, and I thought the US healthcare system was messed up…

Tell me about it!!

Met with my new provider yesterday. She gave me hope and assured me she will do whatever it takes to get me on a pump. Also got another A1c done. I thought for sure it would have been over 7 because I had been a little careless quite a few times knowing it might be easier to get a pump with a higher A1c…but it was 5.7??? I seriously was shocked! I know I should be super happy with that but it just makes me worried I won’t get a pump at all, even with my new Endo fighting as hard as she can. We will see I guess!

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@jtenneson

Slightly over a month since your last post. Has anything changed for you?